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Patient Information Form TITLE: Miss / Mrs / Ms / Mr / Other __________________ SURNAME: GIVEN NAMES: Date of Birth: Sex: M / F ADDRESS: ________________________________________________Postcode___________ PHONE: (h)_________________(w)_________________(mobile)______________ EMAIL Address: _____________________________________________________ Medicare Card Number: __ __ __ __ __ __ __ __ __ __ No: next to name: __________ Expiry: __ __/__ __ Department of Veterans Affairs File No: ____________________ Health Fund: ________________________ Member No:____________________ Next of Kin: Phone: Contact Address MEDICAL HISTORY Current Medications: Allergies: Do you take aspirin or blood thinner regularly? Y / N ______________________ Are you pregnant? Y / N Are you a smoker? Y / N Have you ever had any of the following: Heart conditions Y / N Bleeding disorders Y / N Joint replacement Y / N Hepatitis/HIV/Aids Y / N Cancer treatment Y / N Rheumatic Fever Y / N Other conditions that may be relevant: __________________________________ PAYMENT: To reduce the cost of rendering accounts, it is requested that all consultations fees are paid on the day of consultation. All surgical fees should be paid prior to surgery, otherwise accounting fees may be charged. The information provided above is correct to the best of my knowledge, and I understand conditions of payment. SIGNATURE: DATE: P.T.O Patient Information Form CONSENT TO COLLECT PATIENT’S INFORMATION Recent changes to the Privacy Laws now mean that a person’s written consent is required for a health professional to obtain medical information concerning that person, and to communicate medical information about that person with another health practitioner. In view of this, the following form will need to be signed if you are happy for Dr John Cosson to obtain such information and to liaise with other health practitioners concerning your condition. I,(name)…………………………………………………D.O.B…………………….. Address:……………………………………………………………………………… ………………………………………………………………………………………… give permission for Dr John Cosson 1) To obtain medical information, details of previous consultation and results of investigations performed from other medical practitioners, hospitals and health care providers that pertain to my medical condition. 2) To communicate with the referring medical practitioner concerning my medical condition. 3) To communicate with other health professionals directly involved with my medical condition. Please note: Any OPG’s (xrays) or Scans which are left at the premises of Coastal Oral and Facial Surgery that have not been collected within 12mths will be disposed of. Signature………………………………………………………………………………. Date …………………………………………………………………………………… Name (Parent/Guardian if Patient if under 18yrs): ………………………………………